Organization
BEACON MEDICAL GROUP
Active
Other names
Memorial Children's Hospital Navarre Pediatrics
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY COSTELLO (VP-CFO)
(574) 647-3549
Entity
Organization
Contact information
Practice address
100 NAVARRE PL, SUITE 4400, SOUTH BEND, IN 46601-1156
(574) 647-4535
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
01024987A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
15D1038973
CLIA NUMBER
IN
Enumeration date
05/18/2006
Last updated
03/09/2016
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